13.0 Audit

13.1 Background

Pacific Blue Cross has process controls in place to ensure that Claims submitted are appropriate and compliant with the PROVIDERnet Terms & Conditions. In addition, Pacific Blue Cross employs a comprehensive audit approach to gain further assurance that Claims submitted by Providers are accurate and valid.

All Claims submitted to Pacific Blue Cross may be subject to audit by our Claims Fraud and Abuse Investigations Department. Audits are performed to ensure Claims, and other amounts paid by Pacific Blue Cross are in compliance with the applicable Policy and the PROVIDERnet Terms & Conditions.

It is important to note that successful adjudication of a Claim does not prohibit Pacific Blue Cross from auditing the Claim or the Provider that submitted the Claim.

13.2 Audit Process

Audits are performed by the Pacific Blue Cross Claims Fraud and Abuse Investigations Department.

Pacific Blue Cross investigators are staff or agents of Pacific Blue Cross and are authorized to conduct audits and investigations for the organization.

Audits may be conducted on-site at the Provider's Location or via a desk audit, or a combination thereof.

An audit may employ different evidence gathering methods such as, but not limited to, telephone or in-person staff/agent interviews, written correspondence, and Member/Provider verification letters.

13.3 Audit Selection

Selection of a Provider for audit may be made by selective audit sampling, payment analytics and comparison of claims data, tips received through the Pacific Blue Cross Whistleblower hotline, complaint, or other means.

13.4 Audit Notification

A Provider will be notified of the audit by means of a formal letter.

If the Provider is selected for an on-site audit, Pacific Blue Cross will contact the Provider in advance of the date and time for the on-site audit to provide at least fourteen (14) days prior notice to the Provider, unless Pacific Blue Cross has reasonable grounds to believe that the Provider would not cooperate with the investigators if given such notice.

Notification of a desk audit does not preclude Pacific Blue Cross from initiating an on-site audit if the record and documentation review supports a more in-depth audit.

13.5 Access

If a Provider Location is selected for an on-site audit, the Provider will ensure that all Location staff and its agents will co-operate with the audit. This includes:

Providing Pacific Blue Cross investigators with access to the Location

Granting access to the original required records for review, copying and scanning

13.6 Auditable Records

During an audit, Pacific Blue Cross may review all Supporting Documents. Supporting Documents include all documents, records and information arising from or related to a Claim, including treatment plans, invoices, receipts, appointment records, prescriptions, and Member charts, among others.

For five (5) years after a Claim is submitted, the Provider must retain and make available for the purposes of an audit all relevant original Supporting Documents.

Manufacturer, distributor, and wholesaler invoices

Prescription records and associated documentation

Relevant inventory management records

Schedules of past and current staff at the Provider Location

Patient charts and appointment records

Any other record that is relevant to Claims submissions, billings and payments

Desk Audit Requests

If a Provider is selected for a desk audit, a request will be made by formal letter for copies of relevant records. The Provider has twenty-one (21) days, or a longer time as agreed by Pacific Blue Cross, to provide the requested records.

On-Site Audit Documentation

If a Provider Location is selected for an on-site audit, Pacific Blue Cross investigators or agents will make copies of the Supporting Documents at the time of the on-site audit. Any Supporting Documents which are not made available to Pacific Blue Cross at the conclusion of the on-site audit will be noted and the Provider will be provided twenty-one (21) days, or a longer time as agreed by Pacific Blue Cross, to provide the requested Supporting Documents.

13.7 Non-Compliance

If the Provider does not cooperate with an Audit, or provide copies of Supporting Documents within twenty-one (21) days or such longer time as agreed by Pacific Blue Cross, or other information requested by Pacific Blue Cross, then Pacific Blue Cross may, by notice to the Provider, deem that money paid by Pacific Blue Cross to such Provider was an Ineligible Expense and such Provider will be required to pay the full amount of such Ineligible Expense to Pacific Blue Cross.

13.8 Result Letter

A result letter will be provided to the Provider at the conclusion of the audit.

The results of the audit; and

The amount of any Ineligible Expenses which the Provider must pay to Pacific Blue Cross

Response Timeline

The Provider Location has thirty (30) days, or a longer time as agreed by the parties, to respond to the result letter by:

Confirming the results; or

Requesting reconsideration of the results and providing relevant additional information, documents or materials to support the request. Reconsideration may be requested for the following reasons:

Identification of recovery calculation errors; and/or
Identification of information, documents or materials that may have been overlooked

Final Resolution

If the Provider Location does not respond within thirty (30) days, or a longer time as agreed by the parties, then Pacific Blue Cross will reasonably conclude that no response is forthcoming, and the result letter will stand to identify the conclusion of the audit.

If the Provider Location requests a reconsideration and Pacific Blue Cross may issue a new result letter after PBC reviews the request.

The result letter will identify conclusion of the audit with either:

No further action; or
Required recovery of the Ineligible Expense

In the event of a recovery of an Ineligible Expense, the result letter will outline any recovery options, if applicable.

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